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EP3597222A1 - Behandlung und diagnose von nicht ausbehandelten entzündungskrankheiten - Google Patents

Behandlung und diagnose von nicht ausbehandelten entzündungskrankheiten Download PDF

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EP3597222A1
EP3597222A1 EP18183584.4A EP18183584A EP3597222A1 EP 3597222 A1 EP3597222 A1 EP 3597222A1 EP 18183584 A EP18183584 A EP 18183584A EP 3597222 A1 EP3597222 A1 EP 3597222A1
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apoe
complement
complex
cell
compound
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P29/00—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID]
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A61P25/28—Drugs for disorders of the nervous system for treating neurodegenerative disorders of the central nervous system, e.g. nootropic agents, cognition enhancers, drugs for treating Alzheimer's disease or other forms of dementia
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P9/00—Drugs for disorders of the cardiovascular system
    • A61P9/10—Drugs for disorders of the cardiovascular system for treating ischaemic or atherosclerotic diseases, e.g. antianginal drugs, coronary vasodilators, drugs for myocardial infarction, retinopathy, cerebrovascula insufficiency, renal arteriosclerosis
    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12N—MICROORGANISMS OR ENZYMES; COMPOSITIONS THEREOF; PROPAGATING, PRESERVING, OR MAINTAINING MICROORGANISMS; MUTATION OR GENETIC ENGINEERING; CULTURE MEDIA
    • C12N15/00—Mutation or genetic engineering; DNA or RNA concerning genetic engineering, vectors, e.g. plasmids, or their isolation, preparation or purification; Use of hosts therefor
    • C12N15/09—Recombinant DNA-technology
    • C12N15/11—DNA or RNA fragments; Modified forms thereof; Non-coding nucleic acids having a biological activity
    • C12N15/113—Non-coding nucleic acids modulating the expression of genes, e.g. antisense oligonucleotides; Antisense DNA or RNA; Triplex- forming oligonucleotides; Catalytic nucleic acids, e.g. ribozymes; Nucleic acids used in co-suppression or gene silencing
    • A—HUMAN NECESSITIES
    • A01—AGRICULTURE; FORESTRY; ANIMAL HUSBANDRY; HUNTING; TRAPPING; FISHING
    • A01K—ANIMAL HUSBANDRY; AVICULTURE; APICULTURE; PISCICULTURE; FISHING; REARING OR BREEDING ANIMALS, NOT OTHERWISE PROVIDED FOR; NEW BREEDS OF ANIMALS
    • A01K2267/00—Animals characterised by purpose
    • A01K2267/03—Animal model, e.g. for test or diseases
    • A01K2267/0306—Animal model for genetic diseases
    • A01K2267/0312—Animal model for Alzheimer's disease
    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12N—MICROORGANISMS OR ENZYMES; COMPOSITIONS THEREOF; PROPAGATING, PRESERVING, OR MAINTAINING MICROORGANISMS; MUTATION OR GENETIC ENGINEERING; CULTURE MEDIA
    • C12N2310/00—Structure or type of the nucleic acid
    • C12N2310/10—Type of nucleic acid
    • C12N2310/14—Type of nucleic acid interfering N.A.

Definitions

  • Apolipoprotein E (hereinafter ApoE) is a polymorphic protein arising from three alleles at a single gene locus. It is a multidomain lipid-binding protein largely produced by the liver but neuronal cells and - in particular - brain cells including microglia cells can produce ApoE under stress conditions as well (Mahley, 1988; Mahley et al., 2009).
  • the human isoforms of ApoE i.e. ApoE2, ApoE3 and ApoE4 differ in amino acid residues 112 and 158 located outside the N-terminal receptor- and C-terminal lipid-binding domains, respectively, thereby yielding proteins with different impacts on tissue homeostasis (Bell et al., 2012; Holtzman et al., 2012; Kanekiyo et al., 2014; Linton et al., 1995; Mahley and Huang, 2012; Plump et al., 1992; Zlokovic, 2013).
  • ApoE depending on its isoform, its cellular source, the nature of the lipid moiety it binds and further multiple genetic and environmental risk factors, can act through multiple pathways. Notions regarding mechanisms of action of ApoE include isoform-specific domain-domain interactions (Zlokovic, 2013); involvement of lipoprotein receptors (Holtzman et al., 2012; Kanekiyo et al., 2014); effects on cholesterol efflux (Mahley and Huang, 2012); maintenance of the blood brain barrier (BBB) (Bell et al., 2012; Zlokovic, 2013); and binding extracellular molecules including beta amyloid peptide and heparan sulfate proteoglycans (Holtzman et al., 2012). This wide range of activities indicates that ApoE exercises its functions in complex territorialized tissue contexts.
  • AD Alzheimer's disease
  • LOAD late onset AD
  • sporadic AD a progressive neurodegenerative disease
  • ApoE2 isoform protects from LOAD and sporadic AD.
  • the complement system is an important part of the immune system that enhances (complements) the ability of antibodies and phagocytic cells or other immune cells to clear microbes and damaged cells from an organism, promotes inflammation, and attacks pathogens in multiple ways including inflicting their death via the terminal complement complex (TCC).
  • TCC terminal complement complex
  • the complement system also has multiple additional effects on the immune system and activates inflammasomes whose action is presently the focus of international research efforts (Hajishengallis et al., 2017; Hess and Kemper, 2016).
  • the complement system consists of a number of small proteins found in the blood, many of which are synthesized by the liver. Complement constituents normally circulate as inactive precursors (precursor complement proteins, also referred to frequently as pro-proteins).
  • the complement system becomes tissue-bound under distinct disease or acute repair conditions.
  • proteases in the system cleave specific proteins to release downstream molecules and initiate an amplifying cascade of further cleavages.
  • the result of this activated complement cascade is stimulation of immune cells to clear foreign and damaged material, proxy inflammation to attract additional immune cells, and formation and activation of the cell-killing TCC.
  • New functions of the complement systems are emerging through recent research: These functions are largely beneficial but can turn into disease-relevant and disease-promoting impacts in unresolvable inflammatory diseases requiring therapy (Brennan et al., 2016).
  • the complement system plays important physiological roles as evidenced by synapse pruning during normal development of the brain, it may act intracellularly, and it skews the immune system into distinct directions either in beneficial or detrimental ways (Kolev et al., 2014; Stevens et al., 2007). In unresolvable inflammation, however, overactivation of the CCC and other complement pathways causes disease.
  • the C1-complex is composed of one hexameric C1q molecule (comprising 2 x C1qa, 2 x C1qb, and 2 x C1qc proteins), two molecules of C1r and two molecules of C1s, referred to as C1qr 2 s 2 .
  • C1qr 2 s 2 This occurs when C1q binds to immunoglobulins such as IgM or IgG complexed with antigens, surfaces or by other means by a variety of activators. This also occurs when C1q binds directly to the surface of the pathogen or other activating surfaces.
  • C1r 2 s 2 complex now splits C4 and then C4b-bound C2, producing C4a, C4b, C2a, and C2b.
  • C4b and C2b (historically, the larger fragment of C2 was called C2a but is now referred to as C2b) assemble to form the C3-convertase (C4b2b complex), which promotes cleavage of C3 into C3a and C3b.
  • C3b later joins with C4b2b to generate C5 convertase (C4b2b3b complex).
  • Complement component 5 (hereinafter C5) is the fifth component of complement, which plays an important role in inflammation and cell killing.
  • This protein is composed of alpha and beta polypeptide chains that are linked by a disulfide bridge.
  • An activation peptide, C5a which is an anaphylatoxin that possesses potent spasmogenic and chemotactic activity, is derived from the alpha polypeptide via cleavage by a C5-convertase.
  • the C5b macromolecular cleavage product can form a complex with the C6 complement component, and this complex is the basis for formation of the TCC which is also referred to as the membrane attack complex (MAC), which includes additional complement components (Brennan et al., 2016; Hajishengallis et al., 2017).
  • MAC membrane attack complex
  • Eculizumab sold under the trade name Soliris, is a medication used to treat the diseases, i.e. paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS). It is a humanized monoclonal antibody functioning as a terminal complement inhibitor, having complement protein C5 as target. Eculizumab inhibits terminal complement activation and therefore makes people vulnerable to infection with encapsulated organisms, in particular to meningococcal infections (Brennan et al., 2016).
  • PNH paroxysmal nocturnal hemoglobinuria
  • aHUS atypical hemolytic uremic syndrome
  • siRNA Small interfering RNA
  • RNA interference pathway RNA interference pathway
  • siRNAs small interfering RNA
  • US 2017/183659 discloses antisense nucleotide agents (e.g. si-RNAs) for inhibiting expression of complement component C5 wherein the agent comprises 4 to 50 nucleotides, wherein all nucleotides or a part thereof may be modified nucleotides.
  • the agents are used for treating disorders which benefit from inhibiting or reducing the expression of a C5 mRNA such as PNH and aHUS.
  • EP 3034510 discloses oligonucleotides which may be siRNAs for the treatment of unwanted immune responses, inflammatory diseases and neurological diseases.
  • WO2016/044419 and WO2016/201301 disclose double stranded ribonucleic acid agents for inhibiting expression of complement component C5 and pharmaceutical compositions comprising said agents for treatment of a variety of diseases which benefit from reduction or inhibition of the expression of complement component C5, including PNH and aHUS, atherosclerosis and AD.
  • Amyloid ⁇ forms insoluble aggregates in the brain and there it is a pathological hallmark of AD plaques.
  • WO2011/109246 discloses a method of reducing binding of apolipoprotein E4 (apoE4) to an amyloid- ⁇ -peptide (e.g. an amyloid plaque) in the brain of an individual (thereby treating AD) which comprises administering a synthetic antibody specifically binding to an epitope in apoE.
  • apoE4 apolipoprotein E4
  • an amyloid- ⁇ -peptide e.g. an amyloid plaque
  • US 2015/0337030 relates to methods of treating, preventing or delaying the onset of sporadic AD in a subject, the methods comprising administering to the subject a therapeutically effective amount of an antibody that binds to the ApoE4 protein or a peptide or a peptidomimetic that binds to the ApoE4 protein, or an antisense RNA or an si-RNA that inhibits expression of the gene that encodes the ApoE4 protein.
  • a further embodiment of the present invention is a method for identifying a compound suitable for the prevention or treatment of a disease characterized by an unresolved inflammation condition in accordance with claim 7.
  • a still further embodiment of the present invention is a diagnostic method for the diagnosis of aging-associated diseases, in particular AD and atherosclerosis or other forms of dementia or inflammatory brain disease, wherein the level of a complex resulting from the interaction of C1q with ApoE in the choroid plexus is monitored by an imaging method.
  • Isolated antigen binding construct capable of specifically binding to an interaction of ApoE and C1q or of ApoE with A ⁇ or capable of modulating the expression of complement component C5 or its components C5a and C5b or variants thereof of any complement constituent that arises between the C1q complex and C5 or its cleavage product or complement receptors are another embodiment of the present invention.
  • compositions comprising a compound for use in accordance with any of claims 1 to 6 or an isolated antigen binding construct in accordance with claim 11 and a pharmaceutically acceptable carrier, stabilizer or excipient are a further subject of the present invention.
  • the present invention provides a compound for use in the treatment or prevention of a disease or condition in a mammalian subject wherein the compound is a modulator (antagonist or agonist) of the expression, function or stability of the interaction of ApoE with C1q or of ApoE and A ⁇ or of complement component C5 or its cleavage products C5a and C5b or variants thereof or of any complement constituent that arises between C1q and the C5 complement constituent and its cleavage products or complement receptors on immune cells or tissue cells and wherein said disease is selected from unresolved inflammatory conditions.
  • a modulator antagonist or agonist
  • Inflammation is a normal component of host defence, but unresolved or chronic inflammation is a core perturbation in a range of chronic diseases.
  • inflammation accompanies tumor growth and may be beneficial or detrimental.
  • tissue injury e.g. an infection for example
  • a variety of biological mediators trigger an acute inflammatory response in and by immune cells or tissue cells in which inflammatory molecules are involved.
  • immune agents withdraw leading to restoration of tissue homeostasis.
  • chronic inflammatory diseases i.e. conditions designated herein as unresolved inflammatory conditions, follow (Mohanta et al., 2014).
  • the compound is an inhibitor or antagonist or agonist of said expression, function or stability of C1q or of the interaction of ApoE with C1q or of ApoE with A ⁇ or of complement component C5 or its cleavage products C5a and C5b or variants thereof or of any complement constituent that arises between the C1q complex and C5 or cleavage products thereof or complement receptors expressed on any cell (Brennan et al., 2016).
  • the compound is an antigen-binding construct e.g. an antibody or an antibody-like molecule or other antigen-binding derivative or an antigen-binding fragment thereof that binds said C1q or said interaction of ApoE with C1q or of ApoE with A ⁇ or complement component C5 or its cleavage products C5a and C5b or variants thereof or any complement constituent that arises between the C1q complex and C5 or cleavage products thereof or complement receptors on any cell .
  • an antigen-binding construct e.g. an antibody or an antibody-like molecule or other antigen-binding derivative or an antigen-binding fragment thereof that binds said C1q or said interaction of ApoE with C1q or of ApoE with A ⁇ or complement component C5 or its cleavage products C5a and C5b or variants thereof or any complement constituent that arises between the C1q complex and C5 or cleavage products thereof or complement receptors on any cell .
  • the term "antigen binding construct” includes all varieties of antibodies, including binding fragments thereof. Further included are constructs that include 1, 2, 3, 4, 5, and/or 6 complementarity-determining regions (CDRs). In some embodiments, these CDRs can be distributed between their appropriate framework regions in a traditional antibody. In some embodiments, the CDRs can be contained within a heavy and/or light chain variable region. In some embodiments, the CDRs can be within a heavy chain and/or a light chain. In some embodiments, the CDRs can be within a DNA sequence encoding a single peptide chain. In some embodiments, the CDRs can be within two or more peptides that are covalently linked together.
  • CDRs complementarity-determining regions
  • the antigen binding proteins are non-covalent, such as a diabody and a monovalent scFv. Unless otherwise denoted herein, the antigen binding constructs described herein bind to the noted target molecule.
  • the compound for use in accordance with the present invention may in one embodiment of the present invention be a nucleic acid, in particular a si-RNA (small interference RNA) or an anti-sense nucleotide molecule and/or shRNA molecule that binds to a nucleic acid that encodes or regulates the expression of (i) C1q or the interaction of ApoE with C1q or of ApoE with A ⁇ or complement component C5 or of complement component C5 or its cleavage products C5a and C5b or variants thereof or any complement constituent that arises between the C1q complex and C5 or cleavage products thereof or one or more complement constituent receptors on any cell or (ii) a gene that controls the expression, function and/or stability of C1q or the interaction of ApoE with C1q or of ApoE with A ⁇ or complement component C5 or of complement component C5 or its cleavage products C5a and C5b or variants thereof or any complement constituent that arises between the C1q complex and C5
  • small interference nucleotide molecules may be mentioned here as particularly preferred compounds for use in the present invention.
  • any compound capable of fulfilling the functions defined above is also suitable.
  • Suitable small interference nucleotide molecules are e.g. agents developed by Alnylam Pharmaceuticals Inc. and described i.a. in US 2016/0244763 , US 2015/0247143 , WO 2016/201301 , WO 2016/044419 , EP 3034510 and US 2017/183659 to which reference is made for further details.
  • the skilled person is aware of suitable siRNA agents and will select the suitable agent based on his professional knowledge and the specific application case.
  • the unresolved inflammatory condition can be regulated and controlled, respectively, reduced or - under distinct disease conditions - enhanced.
  • the unresolved inflammatory condition is an aging-associated disease, in particular AD or other forms of dementia or neurodegenerative diseases including vascular dementia or atherosclerosis or ChP injury of patients with cognitive decline.
  • An aging-associated disease is a disease that is most often seen with increasing frequency with increasing senescence. Essentially, aging-associated diseases are complications arising from senescence. Age-associated diseases are to be distinguished from the aging process itself because all adult beings age, save for a few rare exceptions, but not all adult beings experience all age-associated diseases.
  • Examples of aging-associated diseases are atherosclerosis and cardiovascular disease, cancer, many forms of arthritis, cataracts, AMD, osteoporosis, type 2 diabetes, hypertension, ChP injury of patients with/without cognitive decline, and AD and many other forms of dementia and cognitive decline.
  • the compounds for use in the present invention may in particular be used for the treatment and diagnosis of atherosclerosis or AD or other diseases associated with cognitive decline or unresolved inflammation.
  • C1q and A ⁇ form complexes with ApoE in vivo in AD plaques (C1q-ApoE complexes and A ⁇ -ApoE complexes, respectively) as evidenced by the proximity ligation assay (PLA) method.
  • PKA proximity ligation assay
  • the C1q-ApoE complex has a modulating and activity-regulating effect on the complement cascade which could be evidenced by the successful treatment using C5 siRNA molecules and by experimental data of various transgenic ApoE knockin mice.
  • the C1q-ApoE complex was identified in diseased ChPs, AD plaques, other brain areas, and atherosclerosis and many other unresolvable inflammatory diseases whereas the A ⁇ -ApoE complex was found in AD brains. Most if not all chronic inflammatory diseases are associated with activation of one or more complement pathways (Hajishengallis et al., 2017).
  • Each of the binding partners of the C1q-ApoE complex or the A ⁇ -ApoE complex may be subject to separate regulatory events, depending on multiple variables including the state of the immune system, age, the type of the injurious agent, and territorialized tissue contexts. These conditions may ultimately determine the concentration and impact of the C1q-ApoE complex or the A ⁇ -ApoE complex in specific disease conditions. It is believed that the C1q-ApoE complex forms an active disease-relevant regulatory module as indirectly evidenced by the frequent occurrence of autoimmune diseases or immune deficiencies in patients afflicted with genetic absence or loss of function mutations in C1q, C2, C4, and other components of the CCC (Hovland et al., 2015; Zhang et al., 2013).
  • Another embodiment of the present invention relates to a method for identifying a compound suitable for the prevention or treatment of a disease characterized by an unresolved inflammation condition comprising the step of contacting at least one of C1q or the interaction of ApoE with C1q or of ApoE with A ⁇ or the complement component C5 or its cleavage products C5a and C5b or variants thereof and/or a cell expressing C1q, complement component C5 or its cleavage products C5a and C5b or variants thereof or of any other complement constituent that arises between the C1q complex and C5 or cleavage products thereof or complement constituent receptor expressed on any cell, with at least one compound that potentially modulates the interaction of ApoE with C1q or A ⁇ , preferably the interaction of ApoE with C1q in a cell or outside of the cell or which potentially modulates the expression of complement component C5 or its components C5a and C5b or variants thereof in a cell or extracellularly in tissues, and thereafter identifying a modulation of
  • Another embodiment of the present invention relates to an isolated antigen-binding construct capable of specifically binding to an interaction of ApoE with C1q or ApoE with A ⁇ or capable of modulating the expression of complement component C5 or its components C5a and C5b or variants thereof wherein said antigen-binding construct or variants thereof inhibits or enhances the expression of complement component C5 or its components C5a and C5b or variants thereof or of other complement pathway-related molecules which are modified as a result of the modulation of the C1q-ApoE or A ⁇ -ApoE complex.
  • Such antigen binding construct enables the control of the level of C1q-ApoE complex or of the A ⁇ -ApoE complex and thereby the control and regulation of the diseases indicated above for which the C1q-ApoE complex or the A ⁇ -ApoE are important indicators.
  • a still further embodiment of the present invention relates to a pharmaceutical composition
  • a pharmaceutical composition comprising a compound for use in the treatment or prevention of a disease or condition in a mammalian subject wherein the compound is a modulator of the expression, function or stability of C1q or of the interaction of ApoE with C1q or with A ⁇ or of complement component C5 or its cleavage products C5a and C5b or variants thereof or of any other complement constituent or complement constituent receptor expressed on tissue or immune cells.
  • the pharmaceutical composition does also contain a pharmaceutically acceptable carrier, stabilizer or excipient. Suitable carriers, stabilizers and excipients for pharmaceutical compositions have been described elsewhere in the literature and the skilled person will select the suitable components of the composition based on his professional expertise and the individual application case.
  • excipient is a substance formulated alongside the active ingredient of a medication, included for the purpose of long-term stabilization, bulking up solid formulations that contain potent active ingredients in small amounts (thus often referred to as “bulking agents", “fillers”, or “diluents”), or to confer a therapeutic enhancement on the active ingredient in the final dosage form, such as facilitating drug absorption, reducing viscosity, or enhancing solubility.
  • Excipients can also be useful in the manufacturing process, to aid in the handling of the active substance concerned such as by facilitating powder flowability or non-stick properties, in addition to aiding in vitro stability such as prevention of denaturation or aggregation over the expected shelf life.
  • Common excipients are antiadherents, binders, coatings, colors, disintegrants, flavors, glidants, lubricants, preservatives, sweeteners, and sorbents which may be mentioned as examples.
  • compositions in accordance with the present invention can be used in a method for treating or preventing diseases or conditions involving unresolved inflammation in a patient wherein an effective amount of said pharmaceutical composition is administered, preferably in methods where the disease or condition is an aging-associated disease, in particular ChP injuries, AD or atherosclerosis.
  • C1q-ApoE complex formation or the A ⁇ -ApoE complex may be evaluated by the so called proximity ligation assay (PLA).
  • PLA proximity ligation assay
  • the C1q-ApoE complex forms in human ChPs in vivo and that its density in ChP lipid-rich areas is higher when compared to lipid-free areas.
  • the A ⁇ -ApoE complex was identified as a pathological hallmark of AD plaques.
  • the interaction product of ApoE with C1q (hereinafter referred to as the C1q-ApoE complex) in the ChP correlates well with lipid deposits in the choroid plexus which in turn correlates with cognitive decline in age-associated diseases, in particular with AD.
  • the complex correlates with atherosclerosis in patients afflicted with carotid artery atherosclerosis.
  • C1q-ApoE complexes formed in vivo also may serve as a control monitor for atherosclerosis inflammation and in general for all unresolvable inflammatory diseases.
  • Imaging of the complex or the A ⁇ -ApoE complex and/or lipid and/or lipid-derivatives and/or lipid-associated inflammation-derivatives (cells, proteins, peptides, miRNAs, and others) in the choroid plexus or in the brain of patients afflicted with cognitive decline or dementia using a variety of methods including antibodies is a new diagnostic tool to study the extent and the prognosis of the diseases.
  • Another embodiment of the present invention thus relates to the use of a complex being the reaction product of ApoE with C1q or with A ⁇ for the diagnosis of disease conditions associated with an unresolvable inflammation, in particular for the diagnosis of AD and other forms of dementia and atherosclerosis.
  • the present invention provides for the first time the possibility to diagnose AD or atherosclerosis through the monitoring of the complexes formed by ApoE with C1q in a living mammalian subject.
  • lipid deposits in the choroid plexus correlates with the presence of the C1q-ApoE complex which in turn correlates with cognitive decline.
  • any diagnostic method that can be performed in living organisms and patients related to lipid and/or lipid-derivatives or calcium deposits, the presence of the C1q-ApoE complex or inflammatory infiltrates in the choroid plexus is of significant value to diagnose future or present cognitive decline or the clinical outcome of atherosclerosis.
  • the choroid plexus is a metabolically particularly active tissue which expresses a number of molecules in a concentrated form. These characteristics of the choroid plexus are suggested to form the basis for imaging technologies that target these characteristics or molecules.
  • AD and other forms of dementia could only be diagnosed with high certainty and quantitative parameters post-mortem; the current diagnostic methods are based on qualitative factors but not on the quantitative measurement of a marker for the development and degree of the diseases.
  • the present invention provides for the first time a quantitative correlation between the level of an identified marker (the C1q-ApoE complex or lipid or inflammatory markers in the choroid plexus) and the degree of development of the disease including cognitive decline.
  • the predisposition of a given mammalian subject to age-associated diseases like AD and atherosclerosis is possible. This opens the possibility for anticipatory and preventive therapies of the said diseases by identifying indirectly the complex levels and based on said determination, to take the necessary steps to regulate the concentration of the C1q-ApoE complex within the desired range or otherwise specifically treat the disease as outlined above targeting any complement constituent or complement constituent receptor on tissue and immune cells.
  • a still further embodiment of the present invention relates to a diagnostic method for the diagnosis of aging-associated diseases, in particular AD and atherosclerosis, wherein the level of lipid, inflammatory cells, and other structural or functional changes in the choroid plexus or other inflammatory tissue reactions including calcium deposits are monitored by an imaging method in vivo.
  • the choroid plexus can be imaged by a variety of methods with various markers or labels, such as Sestamibi, radiolabeled glucose, other radiolabeled compounds assessing various forms of metabolism, labeled immune cells, and various other imaging technologies.
  • the imaging method may vary depending on the underlying disease but it may be a radiolabeled marker of metabolism (for example glucose) or an antibody directed against a glucose transporter.
  • the choroid plexus is one if not the most metabolically active tissue in the mammalian body expressing hormone binding protein and transporters, ion channels, glucose transporters and many more (Lun et al., 2015; Schwartz and Baruch, 2014). Any compound that can image such highly expressed molecules in the choroid plexus is a candidate for disease diagnostics in the brain and in the choroid plexus in particular.
  • C1q-ApoE or A ⁇ -ApoE complex formation can be evaluated using the PLA ex vivo, which is a technique known to the skilled person and which has been described in the literature so that no detailed description needs to be given here.
  • the accumulation of lipid in the choroid plexus correlates with the degree of development of the diseases which may be monitored through the C1q-ApoE complex or other inflammatory markers in choroid plexus.
  • This provides another possibility for a diagnostic method for the diagnosis of aging-associated diseases, in particular cognitive decline (including AD) and atherosclerosis, wherein the level lipid accumulation or any other change in the choroid plexus including a highly expressed molecule or an inflammatory infiltrate is monitored by an imaging method.
  • Suitable imaging methods for the determination of lipid levels have been described in the literature and are known to the skilled person so that no detailed description needs to be given here.
  • ChP leukocytes ( Figure 1f ), endothelial cells ( Figure 1f ), and epithelial cells ( Figure 2a ) accumulated intracellular lipid droplets, as did the ependymal cells lining the ventricle surfaces ( Figure 2b ).
  • the adjacent brain parenchyma underneath the ependymal cells was infiltrated by lipid and leukocytes and exhibited signs of astrocyte activation.
  • Extracellular lipid increased in ApoE -/- versus WT ChPs by ⁇ 18-fold and also localized at the luminal side of the epithelial cells ( Figure 2a ).
  • High-resolution and transmission electron microscopy (TEM) revealed leukocytes/macrophages in the CSF attached to the microvilli at the abluminal side of the ChP; and some of the intraventricular macrophages accumulated lipid yielding a foam cell-like appearance ( Figure 2c ).
  • Igs which we used as a marker of BBB breakdown, accumulated in the perivascular space of the lipid-free brain parenchyma of ApoE-/- and NC or HFD ApoE4-KI mice. However, there was no statistically discernable aggravation of BBB dysfunction as a function of hyperlipidemia ( Figure 2e ).
  • the biological activities of the IFN-related genes range from regulation of autoimmunity by macrophages and DCs to BBB integrity including IFN-induced protein with tetratricopeptide repeats 3 and 1 (ifit3, ifit1), ubiquitin-specific peptidase 18 (usp18), guanylate-binding protein 3 (gbp3), interferon-induced protein 44 (ifi44), receptor transporter protein 4 (rtp4), IFN-regulatory factor 7 (irf7), and interferon, alpha-inducible protein 27 like 2A (ifi27l2a) (see Figure 1h ).
  • IFN-induced protein with tetratricopeptide repeats 3 and 1 ifit3, ifit1
  • usp18 ubiquitin-specific peptidase 18
  • gbp3 guanylate-binding protein 3
  • rtp4 interferon-induced protein 44
  • rtp4 receptor transporter protein 4
  • Irf7
  • liver-derived C5 To examine whether ChP lipid-triggered CCC activation participates in leukocyte infiltration, we chose to specifically target liver-derived C5 using an si-RNA that selectively binds to the liver asialoglycoprotein receptor ( Figure 3c ). Liver C5-si-RNA knockdown led to a large decrease of circulating C5 levels without affecting blood lipoprotein concentrations or body weight ( Figure 3c ). Liver-targeted C5 silencing resulted in substantial decrease of C5 deposits in the ChP ( Figure 4b ) and attenuated CD45 + leukocyte-, CD68 + macrophage-/DC-, and CD3 + T-cell infiltration in ApoE -/- ChPs ( Figures 3d to f ).
  • ChP lipid deposits correlate with cognitive decline in AD. Though ChP lipid deposits have not been reported in AD, it was searched for pathologies in human AD ChPs that may resemble the pathology of ApoE -/- and HFD ApoE4-KI ChPs. 30 age- and gender-matched brains afflicted with various stages of AD-associated pathologies, i.e., Braak & Braak stages for neurofibrillary tangles (NFTs), Thai phase for A ⁇ plaque score, and the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) for neuritic plaque (both NFTs and A ⁇ plaques) burden were investigated.
  • NFTs neurofibrillary tangles
  • CERAD Cere.g., Alzheimer's Disease
  • ChP lipid deposits correlated with all AD neuropathologies ( Figures 5b to 5d ) and ChP lipid content especially correlated with ApoE4 allele carriers ( Figure 5e ).
  • ApoE3/ApoE3 demented AD cases also had a significantly higher rate of ChP lipid positive areas when compared to ApoE3/ApoE3 non-dementia cases ( Figure 5f ).
  • ChP lipid colocalized with C1q, ApoE, and complement C3 and C5 ( Figure 5g , Figures 6a and 6b ).
  • ChP lipid deposits were associated with intraluminal macrophage infiltration, very similar to mouse ApoE -/- ChPs ( Figures 6c, 6d ).
  • Factor H protein deposition was observed in both lipid positive and lipid negative ChPs in dementia cases.
  • C1q-ApoE complexes in ChP and AD A major question that arose from these data was whether the C1q-ApoE complex that was observed in vitro is also formed in vivo.
  • C1q-ApoE complex formation was evaluated using the proximity ligation assay (PLA) with a resolution power of 10-30nm, comparable to resonance energy transfer-type technologies and super-resolution stimulated emission depletion (STED) microscopy was applied in parallel ( Figure 5h ).
  • PPA proximity ligation assay
  • STED super-resolution stimulated emission depletion
  • PLA revealed A ⁇ -ApoE complexes but not ApoE-pTau complexes in AD plaques of demented cases, extending and corroborating findings that ApoE does not bind to pTau in vitro.
  • C1q-ApoE complexes were also present in mouse AD pathologies ( Figure 6h ).
  • C1q-ApoE complexes are involved in AD pathologies by using mouse models of AD or human brains.
  • APPPS1-21 mice carrying a double mutation in the amyloid ⁇ and presenilin genes these mice develop a rapid and severe form of AD pathology during a defined time window early after birth.
  • C1q-ApoE complexes, but not A ⁇ -ApoE complexes were observed in 8 weeks old WT brain cortexes ( Figure 7a ).
  • C1q-ApoE complexes are not limited to inflammation, but may play a role in normal brain homeostasis, i.e. synaptic pruning.
  • C1q-ApoE complexes control atherosclerosis inflammation.
  • the data obtained raised the possibility that other unresolvable human diseases showed similar pathological hallmarks that were identified in ApoE -/- ChPs in mice and human AD brains.
  • atherosclerosis was examined in ApoE -/- mice as 9 complement pathway-related transcripts were found to be >2-fold upregulated in ApoE -/- aortas during development of aortic arch atherosclerosis were found. Strong up-regulation of CCC complement genes in the aorta during early atherogenesis was observed ( Figure 9a , Figures 10a and b ).
  • CCC activation on early atherosclerosis in ApoE -/- mice was supported by a 65% decrease in both thoracic and abdominal aorta atherosclerosis by C5 siRNA ( Figures 9b to 9e ), without affecting blood lipid levels, body weight, or blood leukocyte counts ( Figures 10c to 10g ).
  • CCC activation in human carotid atherosclerosis was examined. Five healthy control arteries on autopsy (type 0-I; American Heart Association classification), six early (type II-III) and nine advanced atherosclerotic plaques (type V-VII) from carotid endarterectomy specimens were stained for CD68 + macrophages/DCs, C1q, ApoE, and C5.
  • CD68 + macrophages, and C1q, ApoE, and C5 protein deposits increased in early and advanced plaques when compared to control arteries ( Figure 9g ).
  • C1q/ApoE co-localization was confirmed by STED microscopy ( Figure 10h ).
  • the C1q-ApoE complex was identified as a pathological hallmark of atherosclerotic plaques ( Figure 9h ) and malondialdehyde-epitopes (MDA2) were observed on the surface of lipid deposits within plaques ( Figure 9i ).
  • a CCC activity-stabilizing C1q-ApoE complex in diseased ChPs, AD plaques, and atherosclerosis was identified.
  • ApoE controls tissue inflammation by binding to and blocking of C1q resulting in taming of the CCC.
  • ApoE qualifies as a physiological and direct regulator of complement inappropriate control of the CCC by ApoE would be predicted to cause CCC malfunction, injurious tissue inflammation, and disease.
  • the chronicity of unresolvable diseases indicates unrelenting overactivation of the CCC as an important pathogenic mechanism.
  • Inflammatory mediators such as A ⁇ fibrils, oxLDL, C-reactive protein, and a large number of agents carrying danger-associated molecular patterns trigger the innate immune system via activation of C1q.
  • the resulting CCC activity is controlled by a series of physiologically important inhibitors such as C1inh and C4bp.
  • Most if not all chronic inflammatory diseases are associated with activation of one or more complement pathways and ApoE is induced in response to multiple acute and chronic types of tissue injury.
  • both C1q and ApoE independently emerged as mediators of innate immunity. Their ancestors can be traced to unicellular organisms where they participate in defense mechanisms.
  • Both C1q and ApoE acquired domains that appear to have emerged from evolutionary pressures as mirrored by separate but also shared binding partners. For example, both C1q and ApoE bind to lipid- and microbial surfaces, A ⁇ fibrils, and heparan sulfate proteoglycans. It is assumed that C1q and ApoE are induced in multiple inflammatory microenvironments and that the C1q-ApoE complex may be a ubiquitous feature of inflammation.
  • Each of the two binding partners of the C1q-ApoE complex may be subject to separate regulatory events, however, depending on multiple variables including the state of the immune system, age, the type of the injurious agent, and territorialized tissue contexts. These conditions may ultimately determine the concentration and impact of the C1q-ApoE complex in specific disease conditions.
  • AD and atherosclerosis share risk factors such as hyperlipidemia, hypertension, obesity, and diabetes mellitus while the second most common form of dementia, i.e. vascular dementia, has been closely related to LOAD. Indeed, the incidence of AD is greatly enhanced in patients with atherosclerosis consistent with common mechanisms of disease progression.
  • the C1q-ApoE complex does not directly address the surprising effect of the ApoE4 isoform vs the ApoE2 and ApoE3 isoforms in LOAD or the differential effects of distinct ApoE isoforms in human atherosclerosis.
  • Lipid deposits were identified in the ChPs of ApoE -/- and HFD ApoE4 replacement mice but no lipid deposits or apparent CCC activities were detectable in either ND ApoE4 or ND ApoE3 replacement ChPs, yet their IFN gene expression signatures are dramatically different.
  • Lipid deposits were identified in the ChPs of ApoE -/- and high fat diet-fed (HFD) ApoE4 mice but no lipid deposits were detectable in either normal chow (NC) ApoE4 or HFD ApoE3 ChPs, suggesting ApoE4-isoform together with hyperlipidemia caused ChP lipid deposition in mice.
  • LOAD and atherosclerosis share risk factors such as hyperlipidemia, hypertension, obesity, and diabetes mellitus, and the incidence of LOAD is greatly enhanced in patients with atherosclerosis consistent with common mechanisms of disease progression.
  • our data raise the possibility to diagnose and prevent the cognitive decline in patients before the irreversible A ⁇ - and tau-pathologies occur in human brains, and suggest novel therapeutic strategies for LOAD, as well as atherosclerosis.

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